Appeals Pharmacist – Temp-to-Hire

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess and analyze all appeal requests to make coverage decisions based on clinical criteria and medical necessity.

• Manage both incoming and outgoing phone communications with physicians, healthcare providers, and patients to assist with appeal requests, respond to inquiries, and address escalations.

• Work in collaboration with internal and external Medical Directors by supplying relevant clinical and medical data necessary for conducting clinical reviews according to health plan criteria.

• Interpret clinical guideline criteria and effectively apply clinical knowledge and resources when making approval and denial decisions across all levels of appeals.

• Conduct peer-to-peer reviews with providers upon request.

• Evaluate scientific literature using primary, secondary, and tertiary drug resources to support decision-making and recommendations for providers.

• Ensure comprehensive and meticulous documentation in prior authorization cases, appeals cases, and overrides.

• Make clinical prior authorization determinations in line with medical necessity and covered benefit guidelines while adhering to established turnaround times.

• Maintain quality and productivity standards for all reviewed cases while fulfilling established turnaround time requirements.

• Stay updated on all communications and revised processes communicated through various channels and integrate them into daily responsibilities.

• Comply with all internal Standard Operating Procedures and follow HIPAA guidelines and policies.

• Provide exceptional customer care and service by addressing inquiries related to customer accounts in a fast-paced, structured environment within designated time frames.

• Ensure adherence to the Capital Rx Code of Conduct, including the obligation to report noncompliance.

⛳️ Requirements

• Active, unrestricted pharmacist license is mandatory.

• A minimum of 1 year of experience in prior authorization review or appeals is required.

• Capability to work independently with minimal supervision while remaining productive in a remote, high-volume, metric-driven environment with fluctuating priorities.

• Must have a designated workspace (such as an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is shielded from noise that may disrupt conversations.

• Excellent oral and written communication skills are essential.

• Proficiency in Microsoft Office Suite and familiarity with clinical resources (e.g., Micromedex, Lexicomp, Clinical Pharmacology) is necessary.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements